Read the information below, sign and return this document to the person who provided you the form.
The School District of County is authorized to collect, use or release social security numbers (SSN) of employees and other
individuals*' for the following purposes, which are noted as either required or authorized by law to be collected. The collection of
social security numbers is either specifically authorized by law or imperative for the performance of the District's duties and
responsibilities as prescribed by law [Fla. Stat. 51 19.071 (5) (a) 2 & 31.
1. Employment eligibility,report to IRS, SSA, UC, and FAWl , including for W-4's and 1-9's [Required by federal statute and
regulation 26 U.S.C. 6051 and 26 C.F.R. 31.601 1 (b)-2,26 C.F.R. 301.6109-1 and 31.3402(0(2)-1, and Fla. Stat. 5 119.071 (5) (a) 61
2. Receipts to employees for wages and Statements required in case of sick pay paid by third parties [Required by federal
statute 26 U.S.C. 6051 and Fla. Stat. 5 119.071 (5) (a) 61
3. Verification of an alien's eligibility for employment, including 1-9 [Authorized by 8 U.S.C. 1324a(b) and 8 C.F.R. 274a.21
4. Income tax withholding (including for annuity and sick leave)lPayroll deductions on Form W-2 [Required by 26 U.S.C.
3402, 26 C.F.R. 31.6051-1 and Fla. Stat. 5 119.071(5) (a) 61
5. Teacher retirement system benefits and contributions [Authorized by Fla. Stat. 5 238.01 et seq., including 238.07, and Fla.
Stat. 5 11 9.071 (5) (a) 61
6. Retirement contributions required for enrollment in Florida Retirement System (FRS) Investment Plan, second election
retirement plan enrollment, or for participation in and contributions to FRS [Required by Fla. Admin. Code 19-1 1.010,
19-1 1.006 and 19-1 1.007 and Fla. Stat. 5 11 9.071 (5) (a) 2 & 6 or required by Fla. Stat. 5 121.051 and 121.071 and Fla. Admin. Code
19-1 3.003 and Fla. Stat. 5 1 19.071 (5) (a) 2 & 61
7. Reports pertaining to deferred vested retirement programs [Required by 26 C.F.R. 301.6057-1 and Fla. Stat. 51 19.071 (5) (a) 61
8 Payments and plan relating to the retiree prescription drug subsidy under 42 C.F.R. 5 423.34 and 42 C.F.R. 5 423.886
[Authorized by 42 C.F.R. 423.884 and Fla. Stat. 5 1 19.071 (5) (a) 61
9. Educator Certification or licensure application, renewal, or add-on, or non-employee registration for professional
development for in-service points or incentive pay [Required by Fla. Stat. 55 101 2.56, and 119.071 (5) (a) 6, and/or authorized
by Fla. Stat. 55 1012.21and 119.071(5) (a) 6 I
10. Criminal history, Level 1a nd level 2 background checks II dentifiers for processing fingerprints by Department of Law
Enforcement/, if SSN is available [Required by Fla. Admin. Code 11C-6.003 and Fla. Stat. 5 119.071 (5) (a) 61
11. Registration information regarding sexual predators and sexual offenders [Authorized by Fla. Stat. 5 943.04351 and
required by Fla. Stat. 5 1 19.071 (5) (a) 2 & 61 ~
12. Reports on staff required to be submitted to Florida Department of Education (DOE), including but not limited to Outof-
County/Out-of-State Verification of Highly Qualified [Authorized and required by Fla. Stat, 5 119.071 (5) (a) 2 & 6 and/or
EDGAR at 34 CFR 80.40(a) or Fla. Stat. 5 1008.321
13. Social security contributions [Required by Fla. Admin. Code 605-3.010 and Fla. Stat. 5 1 19.071 (5) (a) 2 & 61
14. State directory of new hires (including for determining support obligations and eligibility for several federal and state
programs) [Required by federal law 42 U.S.C. 653a and Fla. Stat. 5 409.2576 and Fla. Stat, 5 119.071 (5) (a) I
15. Notice to Payor and Income Deduction notices for child support, or for alimony and child support [Required by Fla. Stat. 5
61.1301 (2)(e) and Fla. Stat. 5 119.071 (5) (a)]
16. Child support enforcement [Required by 45 C.F.R. 307.1 1 and Fla. Stat. 5 61.1 3,742.10 or 409.256.3 or 742.0311
17. Garnishment payment pursuant to a Notice of Levy [Required by Fla. Admin. Code 12E-1.028m and Fla. Stat. 5 11 9.071 (5) (a)]
18. Request from depository for support payments [Required by Fla. Stat. 5 61.1 81. (3)(b) and Fla. Stat. 5 119.071 (5) (a)]
19. Record of remuneration paid to employees [Required by federal regulation 20 C.F.R. 404.1225, Fla. Admin. Code 6088-2.032,
and Fla. Stat. 5 11 9.071(5) (a) 61
20. Unemployment benefits and short term compensation plan [Required by Fla. Stat. Ch. 443, including 443.1 116, and Fla. Stat.
5 11 9.071 (5)(a)6]
21. Unemployment reports from District [Required by Fla. Admin. Code 60BB-2.023 and Fla. Stat. 5 11 9.071 (5) (a) 61
22. Income information disclosure to HUD [Required by federal regulation 24 C.F.R. 5.214 et seq. and Fla. Stat. 5 119.071 (5)(a)6]
23. VendorslConsultants that District reasonably believes would receive a 1099 form if a tax identification number Is not
provided Including for IRS form W-9. [Required by 26 C.F.R. 5 31.3406-0,26 C.F.R. 5 301.6109-1, and Fla. Stat. 5 119.071 (5) (a) 2
& 6
24. Tort claims and tort notices of claim against the School Board [Required by Fla. Stat. 5 768.28 (61, and Fla. Stat. 5 1 19.071 (5) (a)
61
25. Reporting to and reports of worker's compensation injury or death, including for DWC-1 [Required by Fla. Stat. 5440.185
and Fla. Admin. Code 69L-3.003 et seq. and Fla. Stat. 5 11 9.071(5) (a) 61
26. Worker's compensation petitions for benefits and responses thereto [Authorized by Fla. Admin. Code 60Q-6.103 and Fla.
Stat. 5 11 9.071 (5) (a) 61
27. The disclosure of the social security number is for the purpose of the administration of health benefits for a District
employee or his or her dependents [Required by Fla. Stat..§ 119.071 (5)(a) 61
28. The disclosure of the social security number is for the purpose of the administration of a pension fund administered for
the District employee's retirement fund, deferred compensation plan, or defined contribution plan [Required by Fla. Stat. 5
11 9.071 (5)(a)61
29. Use of motor vehicle information from the Department of Motor Vehicles for the District to carry out its functions and to
verify the accuracy of information submitted by agent or employee to District, including to prevent fraud, in connection
with insurance investigations, and to verify a commercial driver's license [Authorized allowed by federal law 18 U.S.C. 2721
et seq. and Fla. Stat. 5 119.071 (5) (a) 61
30. Authorization for direct deposit of funds by electronic or other medium to a payee's account [Required by Fla. Admin. Code
6A-1.0012 and Fla. Stat. 5 119.071(5) (a) 61
31. Identification of blood donors [Authorized by 42 U.S.C. 405 (c)(2)(D)(i)l
32. Employee's and former employee's request for report of exposure to radiation [Authorized by 41 C.F.R. 50-204.33 and .3]
33. Collection and1 or disclosure are imperative or necessary for the performance of the District's duties and responsibilities
as prescribed by law, including but not limited for password identification to the District's network [Authorized by Fla.
Stat. 5 119.071 (5) (a) 6 and required by Fla. Stat. 5 119.071(5) (a) 21
34. The disclosure of the social security number is expressly required by federal or state law or a court order [Required by Fla.
Stat. 55 1012.56 and 119.071(5) (a) 61
35. The individual expressly consents in writing to the disclosure of his or her social security number [Allowed by Fla. Stat. 5
1 19.071 (5) (a) 61
36. The disclosure of the social security number is made to prevent and combat terrorism to comply with the USA Patriot Act
of 2001, Pub. L. No. 107-56, or Presidential Executive Order 13224 [Required by Fla. Stat. 5 1 19.071 (5) (a) 6 ]
37. The disclosure of the social security number is made to a commercial entity for the permissible uses set forth In the
federal Driver's Privacy Protection Act of 1994,lS U.S.C. Sec. 2721 et seq.; the Fair Credit Reporting Act, 15 U.S.C. Sec.
1681 et seq.; or the Financial Services Modernization Act of 1999,15 U.S.C. Sec. 6801 et seq., provided that the
authorized commercial entity complies with the requirements of paragraph 5 in Fla. Stat. 5 119.071 [Allowed by Fla. Stat. 5
119.071 (5)(a)6 ]
38. The disclosure of the social security number is for the purpose of the administration of the Uniform Commercial Code by
the office of the Secretary of State [Required by Fla. Stat. 5 119.071 (5)(a)6]
I hereby acknowledge receipt of this "Statement on the Collection, Use or Release of Social Security Numbers of Employees and
Others"

Please Read the information below.
The School District of I County is authorized to collect, use or release social security numbers (SSN) of students and/or
parentsX* for the following purposes, which are noted as either required or authorized by law to be collected. The collection of social
security numbers is either specifically authorized by law or imperative for the performance of the District's duties and responsibilities
as prescribed by law [Fla. Stat. 51 19.071(5) (a) 2 & 31.
1. Student registration and student identification numbers. [Required to request by Fla. Stat. 51 008.386 and Fla. Stat. 5 119.071
(5) (a) 6.1008.386 notes as an exception: "However, a student is not required to provide his or her social security number as a
condition for enrollment or graduation.7
2. Registration in an adult education program [Required by Fla. Admin. Code 6A-10.0381, if available and/or student identifier, as
required by Fla. Stat. 5 119.071(5) (a) 6.1
3. Tracking of adult students enrolled in a postsecondary program. [Required by Fla. Admin. Code 6A-1.0955(3) (e), and by Fla.
Stat. 5 119.071 (5) (a) 6.1
4. Criminal history, Level 1 and level 2 background checks II dentifiers for processing fingerprints by Department of Law
Enforcement1 Registration information regarding sexual predators and sexual offenders authorized by Fla. Stat. 5
943.04351, i f SSN is available. [Required by Fla. Admin. Code 11C-6.003 and Fla. Stat. 5 119.071 (5) (a)2 61
5. Reports on students required to be submitted to Florida DOE [Authorized by Fla. Stat. 5 119.071 (5) (a) 2& 61
6. Tort claimsand tort notices of claim against the School Board [Required by Fla. Stat. § 768.28 (61, and Fla. Stat. 5 119.071 (5) (a) 61
7. Use of motor vehicle information from the Department of Motor Vehicles for the District to carry out its functions and to
verify the accuracy of information submitted by agent or employee to District, including to prevent fraud, in connection
with insurance investigations, and to verify a commercial driver's license. [Authorized by federal law 18 U.S.C. 2721 et seq.
and Fla. Stat. 5 1 19.071 (5) (a) 61
8 Information received from DOE to locate missing Florida School Children. [Required by Fla. Admin. Code 6A-6.083 and Fla.
Stat. 5 11 9.071 (5) (a) 61
9. National School Lunch Act application verification process ]Eligibility for Free and Reduced Price Meals and Free Milk in
Schools. [Required of the adult, if the person has a number, by federal law 42 U.S.C. 1751 et seq. and federal regulations 7 C.F.R.
245.2 and .3 and Fla. Stat. 5 119.071 (5)(a)61
10. Reports from Department of Motor Vehicles of each student whose driver's license is suspended for excessive unexcused
absences and reports to Department of non-enrollment or non-attendance upon the part of a student who is required to
attend some school. [Required by Fla. Stat. 5322.091 (5) and 51003.27 and Fla. Stat. 5 119.071(5)(a)6]
11. Written verification from employer for vocational education, student follow up. [Required by Fla. Admin. Code 6A-10.0341
and Fla. Stat. 5 119.071(5) (a) 61
12. Child abuse report to DCF, of student victim and subjects of report. [Required by Fla. Admin. Code 65C-29.002 and Fla. Stat. 5
1 19.071 (5) (a) 61
13. Identification of blood donors [Authorized by 42 U.S.C. 405 (c) (2) (D) (i)]
14. The disclosure of the social security number is expressly required by federal or state law or a court order. [Required by Fla.
Stat. 5 119.071 (5) (a) 6.1
15. Collection and1 or disclosure are imperative or necessaryfor the performance of the District's duties and responsibilities
as prescribed by law, including but not limited for password identification to the District's network. [Authorized by Fla.
Stat. 5 1 19.071 (5) (a) 6 and required by Fla. Stat. 5 11 9.071 (5) (a) 21
16. The individual expressly consents in writing to the disclosure of his or her social security number. [Authorized by Fla. Stat.
5 1 19.071 (5) (a) 61
17. The disclosure of the social security number is made to prevent and combat terrorism to comply with the USA Patriot Act
of 2001, Pub. L. No. 107-56, or Presidential Executive Order 13224. [Required by Fla. Stat. 5 1 19.071(5) (a) 61
18. The disclosure of the social security number is made to a commercial entity for the permissible uses set forth in the
federal Driver's Privacy Protection Act of 1994, 18 U.S.C. Sec. 2721 et seq.; the Fair Credit Reporting Act, 15 U.S.C. Sec.
1681 et seq.; or the Financial Services Modernization Act of 1999, 15 U.S.C. Sec. 6801 et seq., provided that the
authorized commercial entity complies with the requirements of this paragraph 5 in Fla. Stat. 5 119.071. [Authorized by
Fla. Stat. 5 1 19.071 (5)(a)6.1
19. Income for Medicaid eligibility, determine the amount of medical assistance payments, process Medicaid billing, and
provide program follow-up [Required by federal regulation 42 C.F.R. 5 435.91 0, unless student applicant for Medicaid refuses to
obtain a social security number, based on well-established religious objections]

The School District of County is authorized to collect, use or release social security number (SSN) of volunteers***
for the following purposes, wnir;l~ are noted as either required or authorized by law to be collected. The collection of social
security numbers is either specifically authorized by law or imperative for the performance of the District's duties and
responsibilities as prescribed by law [Fla. Stat. §I 19.071(5) (a) 2 & 31.
1. Registration information regarding sexual predators and sexual offenders [Authorized by Fla. Stat. § 943.04351 and
required by Fla. Stat. § 119.071(5) (a) 2 & 61
2. Criminal history, Level 1 and level 2 background checks I Identifiers for processing fingerprints by Department
of Law Enforcement/, if SSN is available [Required by Fla. Admin. Code 11C-6.003 and Fla. Stat. 119.071(5) (a) 61
3. Reports required to be submitted to Florida Department of Education (DOE) [Authorized and required by
Flu. Stat. § 1 19.071 (5) (a) 2 & 61
4. Tort claims and tort notices of claim against the School Board [Required by Fla. Stat. 5 768.28 (6), and Fla. Stat. §
11 9.071 (5) (a) 61
5 Reporting to and reports of worker's compensation injury or death, including for DWC-1 [Required by Fla. Stat.
s440.185 and Fla. Admin. Code 69L-3.003 et seq. and Fla. Stat. § 119.071(5) (a) 61
6. Worker's compensation petitions for benefits and responses thereto [Authorized by Fla. Admin. Code 60Q-6.103
and Fla. Stat. 5 11 9.071 (5) (a) 61
7. Use of motor vehicle information from the Department of Motor Vehicles for the District to carry out its
functions and to verify the accuracy of information submitted by agent or employee to District, including to
prevent fraud, in connection with insurance investigations, and to verify a commercial driver's license,
[Authorized by federal law 18 U.S.C. 2721 et seq. and Fla. Stat. 5 119.071(5) (a) 61
8. Identification of blood donors [Authorized by 42 U.S.C. 405 (c)(2)(D)(i) and Fla. Stat. § 119.071(5) (a) 61
9. Collection and1 or disclosure are imperative or necessary for the performance of the District's duties and
responsibilities as prescribed by law, including but not limited for password identification to the District's
network [Authorized by Fla. Stat. 5 119.071(5) (a) 6 and required by Fla. Stat. fj 119.071(5) (a) 21
10. The disclosure of the social security number is expressly required by federal or state law or a court order
[Required by Fla. Stat. §§ 1012.56 and 119.071(5) (a) 61
1 1 . 'The individual expressly consents in writing to the disclosure of his or her social security number [Authorized by
Fla. Stat. 119.071(5) (a) 61
12. The disclosure of the social security number is made to prevent and combat terrorism to comply with the USA
Patriot Act of 2001, Pub. L. No. 107-56, or Presidential Executive Order 13224 [Required by Fla. Stat. § 119.071(5)
(a) 61
13. The disclosure of the social security number is made to a commercial entity for the permissible uses set forth
in the federal Driver's Privacy Protection Act of 1994, 18 U.S.C. Sec. 2721 et seq.; the Fair Credit Reporting Act,
15 U.S.C. Sec. 1681 et seq.; or the Financial Services Modernization Act of 1999, 15 U.S.C. Sec. 6801 et seq.,
provided that the authorized commercial entity complies with the requirements of paragraph 5 in Fla. Stat. g
119.071 [Authorized by Fla. Stat. 5 11 9.071(5)(a)6]
14. The disclosure of the social security number is for the purpose of the administration of the Uniform
Commercial Code by the office of the Secretary of State [Required by Fla. Stat. § 119.071 (5)(a)6]